Promising trends and influencing factors of complementary feeding practices in Côte d'Ivoire: An analysis of nationally representative survey data between 1994 and 2016

Abstract Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6–23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994–2011) and Multiple Indicator Cluster Surveys (MICS, 2000–2016), the trends and predictors of World Health Organization‐United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6–8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011–2016, the proportion of children aged 6–23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi‐level strategies to improve young children's diet in Côte d'Ivoire.


| INTRODUCTION
Côte d'Ivoire has achieved successful progress in reducing child malnutrition but is still experiencing a high prevalence of stunting (United Nations Children's Fund World Health Organization & The World Bank, 2021). From 2000 to 2020, the proportion of stunted children under 5 years of age decreased from 33.6% to 17.8% (United Nations Children's Fund et al., 2021). Côte d'Ivoire experienced economic and political instability during civil wars and, since 2012, economic rebuilding and growth (The World Bank, 2021). War conflicts and economic instability exacerbated socioeconomic hardships (Fürst et al., 2010), posing great challenges for child nutrition.
Adequate child feeding practices play an important role in maintaining nutritional status among infants and young children (Black et al., 2013;Stewart et al., 2013). Exclusive breastfeeding is recommended by the World Health Organization (WHO) for all infants younger than 6 months of age (WHO, 2003). At 6 months, the introduction of other nutrients-and energy-dense foods and liquids is critical for infants and young children (WHO, 2010). According to WHO, appropriate complementary feeding (CF) practices require the timely introduction of complementary foods with adequate frequency and diversity (WHO, 2010). Prior evidence revealed that appropriate CF practices benefit physical growth (Lassi et al., 2013) and neurocognitive development (Morley & Lucas, 1997;Prado et al., 2019) in childhood, and prevent chronic conditions in adulthood (D'Auria et al., 2020). In Côte d'Ivoire, however, CF practices are thought to be poor. In 2016, only 13.6% of children aged 6-23 months were fed with a minimum acceptable diet (MAD) according to recommended CF practices (UNICEF, 2020).

Nationally representative surveys, including the WHO Infant and
Young Child Feeding (IYCF) module to assess CF, have been implemented in Côte d'Ivoire in the past 20 years; however, changes in CF practices over time and its related influencing factors have not been studied. Understanding the trends and risk factors of CF, described as the underlying determinants of child malnutrition by the UNICEF framework, is an appropriate first step to address child malnutrition (United Nations Children's Fund, 2020b). It is also essential to identify the modifiable risk factors related to CF practices to plan and implement effective interventions by targeting at-risk individuals, households and communities (Stewart et al., 2013 conducted data extraction in pairs. Any discrepancy (i.e., inaccurate data extracted from wrong tables in reports) between the researchers were resolved through group discussion until consensus was reached.
To explore the current influencing factors of CF (aim 2), we analyzed the most recent 2016 MICS data. Information on the 2016 MICS survey methodology, sampling procedure and questionnaires has been published previously (Institut National de la Statistique et al., 2016). Briefly, eligible women and children were included based on a two-stage stratified sampling procedure. At the first stage, a total of 512 census enumeration areas were selected with probability as the primary sampling units (PSUs). At the second stage, 25 households were selected by systematic sampling within each PSU. Based on prior studies looking at CF practices in low-and middle-income countries (Na, Aguayo, Arimond, Dahal, et al., 2018;Na, Aguayo, Arimond, Mustaphi, et al., 2018;Na et al., 2017), the inclusion criteria of mother-child pairs to be included in our analysis were: (1) mothers were between 15 and 49 years of age; (2) the youngest singleton child was aged 6-23 months; (3) children were alive at the time of the survey; and (4) children lived with their mothers. We included mothers aged 15-49 years old to decrease the possibility of enroling children with potential health problems born from teenage (<15 years) or older (>49 years) mothers. The study further defined the youngest singleton children aged 6-23 months to avoid potential recall bias and to prevent enroling more than one child from each household. In addition, only alive children living with their mothers were included, so the surveys were able to collect their CF practices from mother-child pairs. • Suboptimal CF practices remain a concern, with 12.5% of children aged 6-23 months meeting MAD in 2016.

| CF practices
• Inappropriate CF practices are significantly associated with factors at individual (child age, maternal education TV watching and currently breastfeeding), household (wealth and urbanicity) and community levels (community-level access to health care). For breastfed children, they are classified as having a MAD when they meet the MMF and MDD standards. For nonbreastfed children, they are classified as having a MAD when they meet the MMF standards and receive at least two milk feedings along with at least four food groups other than milk products.

| Influencing factors
The selection of the influencing factors at the individual, household and community levels was based on the conceptual framework developed by Stewart et al. (2013) and our previous work in South Asia (Na, Aguayo, Arimond, Dahal, et al., 2018;Na, Aguayo, Arimond, Mustaphi, et al., 2018;Na, Aguayo, Arimond, Narayan, et al., 2018;Na et al., 2017). Individual-level factors included child, maternal and paternal characteristics. For children, the following variables were included: sex, age, birth order, birth interval, measured birthweight, perceived birthweight and child morbidity including diarrhoea, fever and cough. Maternal characteristics included age, smoking status, education, marital status, occupation, nutritional status (height and body mass index), breastfeeding practices, utilization of reproductive health care, exposure to media and women's attitude towards domestic violence. Paternal characteristics included age and education. Household-level factors included household structures and socioeconomic status. The household characteristics included the place of residence, sex of household head, number of household members, number of children under five years, types of cooking fuel, water characteristics (source and location of drinking water, time to get to water sources) and quintiles of overall household wealth index (higher quintiles indicate poorer households). The community-level factor described access to health care within the community where the selected subjects lived. Based on the utilization of maternal and child nutrition and health care services among all respondents, the rank score for community access to health care was generated first and then categorized into quintiles. Higher rank scores or quintiles indicate poorer community access to health care. A detailed description of the factors is available elsewhere (Na et al., 2020).

| Statistical analysis
All data analysis was performed using STATA/SE 15.1 (StataCorp). The prevalence of four CF indicators was extracted from the national DHS and MICS reports. Multivariable models were applied to determine the associations between influencing factors and CF indicators among children aged 6-23 months: (1) the bivariate associations between influencing factors and CF indicators were examined first to select the significant risk factors at p= 0.1, and (2) the selected variables from the bivariate analysis were included in the multivariate risk factor analysis.

| RESULTS
The proportion of children meeting CF indicators is presented in    (Table 1). At the community level, access to health care was significantly associated with meeting MMF. Higher access to health care was adversely associated with meeting MMF (Table 1).

| DISCUSSION
Using nationally representative data in Côte d'Ivoire, we found an   In previous studies in other low-income countries where food access is not guaranteed (Mitchodigni et al., 2017;Taha et al., 2020), older children within the 6-23 age range were more likely to be meeting MDD and MAD. A common feeding pattern has been observed in Sub-Saharan African countries, where young children's diets are mostly comprised of grains, roots, and tubers with little variety (Faber, 2005;Macharia-Mutie et al., 2010;Maseta et al., 2008;Sika-Bright, 2010), and to a lesser extent, fruits, vegetables and animal-sources foods, which tend to be consumed as children grow older (Faber, 2005). Another possible explanation proposed by Ali et al. is that limited maternal literacy or awareness levels of feeding practices may also result in poor dietary diversity in older children (Ali et al., 2021). Our study findings on higher maternal education levels associated with higher odds of meeting MDD might support Ali's explanation. As children grew older, rural mothers with lower literacy and awareness levels were more likely to feed their children based on children's demands on certain types of food rather than feeding diverse food types (Ali et al., 2021). However, the MICS 2016 survey still lacked data on maternal awareness levels on child feeding; therefore, future studies are needed to further investigate Ali et al.'s explanation using national-level data in Côte d'Ivoire.
In addition to the child's age and maternal education levels, maternal TV watching, and whether mothers were currently breastfeeding their children were significantly associated with CF practices in Côte d'Ivoire. Maternal media exposure has been identified as a key modifiable risk factor associated with improved CF practices in multiple countries (Beyene et al., 2015;Joshi et al., 2012;Malhotra, 2013). Mass media in Côte d'Ivoire has become an important platform to deliver appropriate feeding information. For example, national TV programmes have broadcast innovative media campaigns to promote the feeding of complementary foods (Hystra, 2014). Caregivers may improve their awareness of child feeding by receiving educational health messages channelled through media (Patel et al., 2012), and educating caregivers on child feeding through mass media is considered acceptable and feasible (Rahman et al., 2012). Besides, owning a TV in the household may be a proxy indicator of household wealth levels, and our findings showed that children from wealthier households had higher odds of meeting all four CF indicators compared to those from poorer households.
Continued breastfeeding was another significant modifiable risk factor influencing multiple CF indicators, including MMF and MAD.
Our finding is consistent with previous evidence from 367 children aged 6-23 months in Ethiopia, where they found that currently breastfed children were 7.5 times more likely to achieve MMF compared to nonbreastfed children (Wagris et al., 2019 Our study had several important strengths, including the use of nationally representative survey data, standardized measurement instruments and procedures from DHS and MICS surveys, and welldesigned analytical methods based on a conceptual framework and previously published work. However, our study also has some limitations. The nature of cross-sectional surveys prevents us from determining causality. The use of self-reported data may raise the possibility of recall bias, as well as respondent bias if mothers respond to survey questions based on perceived interviewers' desirability. Another limitation is the lack of consideration for other possible predictors that might affect the CF practices, such as food availability and allocation of food and financial resources within each household (United Nations Children's Fund, 2020a).